The EPP and the Selection of Cytoscreeners

In the UK, it is recommended that women undergo cervical screening every 3-5 years, from the age at which they become sexually active, to sixty. Screening is carried out via a smear test, which is usually undertaken by a family doctor, or a nurse within the family doctor's clinic. The smear samples cells from the cervix, which are then transferred to a slide. This is then sent to a cytology laboratory for examination.

Cytoscreeners are individuals whose main role is the examination of slides for abnormalities -mainly pre-cancerous and cancerous cells, but also fungal, viral and bacterial infections, and other abnormalities. To examine a single slide may take 1015 minutes, as the slide must be examined over its entire surface, and throughout its depth as cells in the smear sample can overlap one another. A slide may contain as many as 500,000 cells and a screener may be looking for 5-10 abnormal cells amongst those. In addition for a screener to make a decision about a slide they must also consider the medical history of the woman which includes her age, contraceptive use, whether she is pro- or post-menopausal and whether she has had any children.

The standard qualifications required to enter screening are - five O levels or GCSEs are sufficient to be taken on as a trainee screener, selection is then done by interview. Trainees attend a four-week residential training course, and then must train for a minimum of two years in the laboratory. During this time they must complete a logbook of their work and a more experienced worker must re-examine all their work. When they have screened a minimum of 5,000 slides they are eligible to be entered for the Certificate of Competence in Cervical Cytology examination. If they then pass this difficult exam they are eligible to become cytoscreeners, and examine smears on their own.

The training of cytoscreeners is a lengthy and expensive task, and two problems arise. Firstly despite extensive training some screeners never become sufficiently adept to obtain the Certificate of Competence. Secondly they decide not to continue in the profession, either before, or shortly after obtaining the Certificate. Both of these factors place a considerable strain on the resources of a laboratory.

The Project

The co-ordinating body of the NHS Cervical Screening Programme commissioned the Applied Vision Research Unit to carry out research to find a suitable pre-employment test for cytoscreeners, to aid in the selection process. Initial research investigated the aspects of visual skill which were involved in the screening task, and attempted to assess these skills. It became clear, when these studies were unsuccessful, that the visual skill was not the key, the task of screening is not very similar most visual skill measurement tasks. The cells are difficult for the novice to see, but the screeners will be familiar with them. Most visual skill tasks require people to distinguish difficult shapes, with which they are unfamiliar, and require them to do it at speed. In cytological screening the task is much more cognitive, it is not simply the recognition of different shapes, but their interpretation, given the medical history of the woman. In addition, speed is unimportant, but what matters more is the ability to concentrate for long periods of time and maintain vigilance.

It was thought that personality might be a more important factor than visual skill in determining success at screening.

Personality

The particular aspects of personality that were felt to be important were:

Extroversion: Cytological screening is a job that requires long periods of concentration, and provides little stimulation, in addition there is a long history of research that suggests that extroverts perform less well at vigilance tasks than introverts.

Neuroticism: Although the job provides little stimulation, it can be stressful. A mistake, in the form of missing a cancerous, or pre-cancerous smear, can literally be fatal for the woman involved. In addition if high grade cancerous cells are found in subsequent smears, the previous smears which have been taken will be re-examined to see if cancerous signs were present, and the individual who was responsible for screening that smear in the past will be identifiable.

Psychoticism: Neither the financial rewards, nor prospects of promotion are great in screening. It was felt that a person who would make a better screener would have a greater sense of responsibility than non-screeners. In addition both risk-taking and impulsiveness are undesirable characteristics for screeners.

Methodology

The ideal methodology to employ would be a longitudinal one, in which a cohort of screeners would be selected and followed for the first few years of their career. This methodology was rejected because of the length of time it would take before results could be fed back into the screening selection process, and therefore the delay before the economic benefits would be felt. Instead a survey was undertaken of personnel who worked in cytological screening. A random sample of cytology laboratories was taken and sent a questionnaire for each person who worked in the laboratory. This included cytoscreeners, MLSOs and trainee cytoscreeners. The small number oftrainee cytoscreeners was eliminated from the analysis, and, as no significantdifferences emerged between the cytoscreeners and MLSOs (whose main task is also screening) they were combined.

Results

The results displayed here are of a simple comparison of the scores obtained and thescores given In the norm samples provided in the EPP manual, without regard to agegroup and gender. The mean ages were 45.2 (SD 9.5) for cytoscreeners and 42.8 (SD10.1) for MLSOs. The cytoscreeners had been working in screening for a mean of 12.0 years (SD 8.1) and the MLSOs 13.3 years SD (8.6). Considerable differences were found for the three extroversion traits of the EPP. Specifically:

For sociability:

16% (approximately l in 6) of the norm sample score as low as the mean score for cytoscreeners.only 13.9 (approximately 1 in 7) cytology workers score higher than the mean score found in the norm sample. one in twenty (5%) cytology workers score higher than 30, on the sociabilityscale, whereas two out of five (40%) of the norm sample score higher than 30.

For activity:

11% (approximately 1 in 9) of the norm sample score lower than the mean score for cytology workers.only l cytology worker in 10 scores higher than the mean score for the norm sample. the highest score obtained by all 277 respondents on the activity scale was 32, 22% (approximately 1 in 5) of the norm sample scored higher than this.

For assertiveness:

14% (approximately 1 in 7) of the norm sample score lower than the mean score for cytology workers.1 cytology worker in 10 scores higher than the mean score for the norm sample.the highest score obtained by any cytology worker was 28, in the norm sample24% of respondents scored higher than this value.In the neuroticism traits, the differences were less marked:

For anxiety:

60% of people in the norm sample score lower than the mean score for cytology workers

For inferiority:

73% of people in the norm sample score lower than the mean value for cytology workers.

For unhappiness:

The median value for cytology workers is 7, whereas the median for the norm sample is 6.In the three psychoticism traits marked differences again occur:

For risk-taking:

Approximately l in 25 (9 of the sample of 277) cytology workers scored higher than the mean score found in the norm sample for risk-taking.6% of the norm sample scored lower than the median value found for cytology workers on risk-taking.The highest score obtained for all 277 cytology workers was 26. 1 in 5 of the norm sample scored higher than this value.

For impulsiveness:

Approximately 1 in 5 of the cytology workers scored higher than the mean score found in the norm sample1 person in 5 of the norm sample scored less than the median value found in cytology workers.

For irresponsibility:

16.5% (approximately 1 in 6) people working in cytology scored higher than the mean value found in the norm sample.1 person in 3 in the norm sample scored less than the median value found in cytology workers.

These results seem to show some marked differences between individuals who are currently involved in screening and the norm sample.

Conclusions and Implications

The people currently employed in screening seem to be less extrovert and less psychotic than the norm sample. Amongst the neuroticism traits the only difference of any size that was found was inferiority. As a result of this study we will recommend that the EPP be used alongside the existing interview process in the selection of screeners, particularly the extroversion and psychoticism scales. Because the study is only cross sectional we will recommend that the EPP be used in only an advisory fashion, until we have carried out longitudinal research to investigate more thoroughly the ability of the EPP to select appropriate personnel.

Acknowledgement: The initial work in this study was carried out by Dr R Lawson.

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